Abstract

In The Lancet today, Keertan Dheda and co-authors present an interesting report about early treatment outcomes of extensively drug-resistant (XDR) tuberculosis (resistant to isoniazid, rifampicin, any fluoroquinolone, and at least one injectable drug: capreomycin, kanamycin, or amikacin) in South Africa. Culture conversion and mortality, stratified by HIV status, were retrospectively reviewed from the original records of a large cohort of 174 cases diagnosed between 2002 and 2008.
Why is this report relevant? The scientific community is still piecing together the puzzle of XDR tuberculosis, more than 4 years after its first description. In looking more broadly to the issue of XDR tuberculosis, we find the same conundrum that faced the blind men in describing the elephant: is everyone partly right, or are we all mostly wrong?
In addition to questions generated from the findings of treatment outcome studies of patients with XDR tuberculosis, Dheda and colleagues' results provide additional information for debate. Is XDR tuberculosis a death sentence as the European data indicate, or can we really achieve a high proportion of success as the data from Peru suggest? Is the poor outcome in patients with XDR tuberculosis described in KwaZulu Natal related to HIV-positive status as is commonly perceived? Are patients dying despite the availability of antiretroviral treatment? What is the best regimen for treatment of XDR tuberculosis in resource-restricted settings? What is the role of surgery? Are reliable predictors of poor outcome available?
Dheda and colleagues' first finding was that there was no difference in early outcomes (mortality and culture conversion) in individuals with or without HIV infection. This result is important for the design and implementation of treatment programmes to reduce existing stigma associated with co-infection with XDR tuberculosis and HIV, and for advocacy purposes.